Transcript PT 142: Assessment in Physical Therapy Introduction to

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PT 142: Assessment in Physical Therapy
Introduction to
Musculoskeletal/
Orthopedic Assessment
Aila Nica J. Bandong, PTRP
Instructor
Department of Physical Therapy
Clinical Supervisor
CTS-Pediatric Section
UP-College of Allied Medical Professions
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Learning Objectives
At the end of the lecture, the student should
be able to:
• Determine the principles and
concepts of a musculoskeletal
assessment
• Identify cues and information that
needs to be obtained in a subjective
musculoskeletal assessment
• Formulate hypothesis of the
problems assessed and determine
examination procedures that may
confirm or refute a hypothesis
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MODEL OF ORTHOPEDIC DYSFUNCTION
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Systemic Disease
Emotional Tension
Infection
Body System Lesion
Stimulus
Internal Tissue
Response
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Physical
Trauma
Immediate
Tissue
Insufficiency
Altered Mechanical Properties of
Tissues and Structure
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Internal Tissue
Response
Pain
Inflammation
Immediate tissue
insufficiency
Vasodilation
Swelling
Internal tissue
Ischemia
Contractile
Noncontractile
Tissue Irritation
Altered Internal
Tissue
Stress
Functional Soft
Tissue Contracture
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Altered Mechanical Properties of
Tissues and Structure
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Immobilization
Swelling
Altered Internal Tissue
Stress
Non-Contractile Tissue
Fibrous Reaction
Soft tissue
Contracture
Contractile Tissues
Intrinsic
Tissue
Insufficiency
Altered Myotendon
Unit Composition and Dynamic Function
Articular Structures
Altered alignment of joint
Altered Arthrokinematics
Altered
Osteokinematics
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Acquired
Tissue
Insufficiency
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Why perform a comprehensive
examination?
Establish a sound therapeutic relationship with the patient
Make a clinical diagnosis
Identify the goals or outcome of physical therapy
management
Establish a set of baseline data and measurement
procedures that can be used to judge treatment outcomes
Establish the presence of any contraindications or
precautions to treatment
Identify the most appropriate intervention strategy to
achieve goals
Decide upon the dose of the appropriate strategies or
treatments that will be effective in achieving goals
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Components of a Comprehensive
Musculoskeletal/Orthopedic Assessment
Demographic
Data
Subjective
Assessment/
History Taking
Objective
Assessment/
Physical Examination
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DEMOGRAPHIC DATA
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• Name
• Age
• Occupation – identify
work requirements
• Repetitive movements
• Position of limb at work
• Recreational pursuits/
sports
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• Activities of daily
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living
Gender
Marital status
Address
Nationality
Handedness
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DEMOGRAPHIC DATA
• Date admitted ( for in-patients )
• Admitting unit ( for in-patients )
• Attending physician
• Date evaluated
• Date of initial evaluation
• Working diagnosis
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SUBJECTIVE ASSESSMENT
Area and type of
symptoms
Current history/
mechanism of injury
24-hour pain behavior
Aggravating and
alleviating factors
Past history of the
condition (if any)
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Past medical history
Family medical history
Personal/Social history
Ancillary procedures
Medications
Chief complaint
Previous treatment and
effect (if any)
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AREA AND TYPE OF SYMPTOMS
• May employ a body chart
• Identify areas and types of symptoms
• Initial determination of the relationship
between the symptomatic areas
• What are included in the body
chart?
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Area
Constancy
Quality and severity
Relationship of the symptoms
Depth
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Area and Type of Symptoms:
Area
• Provides information regarding:
• Source of the problem
• Prognosis
• Used as baseline measure when monitoring
treatment effects
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Area and Type of Symptoms:
Anesthesia/Paresthesia
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Paresthesia vs. anesthesia
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Paresthesia: altered sensation in an area
Anesthesia: absence of sensation (numbness)
Presence of altered sensation is suggestive
of nerve compromise, particularly if the
symptom distribution is dermatomal
(Helfelt and Greubel 1978)
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Most common cause of altered sensation
accompanying spinal disorders is spinal/
nerve root compromise
(Bogduk 1991)
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Are the symptoms present
continuously?
Does the intensity of symptoms
vary with movement or
positioning?
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Area and Type of Symptoms:
Constancy
Pain or paresthesia that is better
or worse with movement or
positioning is likely to be
musculoskeletal in origin
Provides information regarding
prognosis
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Pain on activity that
decreases with rest
Pain or aching as the
day progress
Resting pain/ pain that is
worse at the beginning
of the activity
Intractable pain
Intermittent claudication
IV disc pain vs. facet
pain
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Area and Type of Symptoms:
Quality
Refers to the description of pain
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Interprets pain based on the pathology or structures involved
Indicates the severity of the pain experience
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As part of a disability questionnaire
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Throbbing diffuse – vasculature/
inflammation
Cramping dull aching – muscle
Sharp shooting – nerve
Deep nagging dull – bone
Sharp severe intolerable –
fracture
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Area and Type of Symptoms:
Intensity
Rating severity of the symptoms based on a scale
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Usually range from 0 (no pain) to 5/10 (severe pain)
Visual Analogue Scale: a 10-cm line with pain descriptors at each
end (“no pain” to “pain as bad as it could be”)
May assist in determining prognosis
May be a reliable indicator of progress as the patient is
providing information regarding the pain experience
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Area and Type of Symptoms:
Depth
It was previously believed that the depth of pain is related to
the depth of injury.
Invalid considering spinal nerve or nerve root involvement
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Imperative to have a good background knowledge of
distribution/referral patterns for anatomical structures
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Muscle pain does not refer superficially
Skin rarely refers pain
Visceral pain has cutaneous
distribution/pattern and sometimes
produce autonomic symptoms
• Joints specifically zygapophyseal joint
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Area and Type of Symptoms:
Relationship of Symptoms
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Evaluate if the symptoms arise from one
source or multiple sources
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Identify whether symptoms are provoked
independently (unrelated) or worsen all
together (related)
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Clinical Implication
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Related symptoms: one area
to be treated to relieve
symptoms
Unrelated symptoms: a need
to treat various areas to
promote relief of symptoms
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CURRENT HISTORY
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History of the present illness
Provides information about the onset of
the disorder
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When the injury happened
Mechanism of injury (how the injury occurred)
Progress of symptoms
Treatment provided (if any) and effects of the
treatment
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Current History:
Onset of Symptoms
Provides information of the relative stage of
injury
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Acute: 0 to 7 days after injury
Sub-acute: 7 days to 7 weeks after injury
Chronic: more than 7 weeks after injury
Allows the therapist to:
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identify appropriate intervention
prognosticate
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An insidious onset not
related to injury or
unusual activity is
suspicious
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Neoplasm
Degenerative lesions
Lesions due to tissue
fatigue
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Current History:
Mechanism of Injury
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Used to formulate diagnosis
Direction, position, and nature of the
injuring force may provide clues which
tissues could have been injured
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Correlation can be made to the signs and
symptoms for interpretation
The magnitude of the injuring force and the
severity of injury can be compared
Take note of unusual injury patterns as
these could be a sign of an abnormal
tissue status prior to injury
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Current History:
Progress of Symptoms
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Inquire if the patient’s symptoms get
better, worse, or essentially status quo
and in what way/manner
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Most musculoskeletal injuries get better over
time primarily due to the normal healing
process (~ 6 weeks)
Some disorders may actually get worse over
time  underlying pathology
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Pain that radiates: extends to include other
areas
Presence of paresthesia following initial pain
Prognosis is good is the patient’s
symptoms are improving
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Current History:
Treatment received and effects
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If the patient has already been treated for
the same injury in the past, or has
received treatment prior to physical
therapy consult, it is important to inquire
about the type of intervention provided
and the effects
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Are noted changes for the better/worse?
Provides information regarding:
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Prognosis
Treatment selection
Dosage of treatment
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24-HOUR BEHAVIOR
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Status of symptoms
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At night
In the morning
Throughout the day: do the symptoms vary?
Knowledge of the behavior of the
symptoms provides information in:
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Formulation of diagnosis
Identifying plan of care
Monitoring of the progress of condition
Prognosis but only to a lesser extent
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24-Hour Behavior:
Night Pain
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Night time symptoms
• Intractable pain –
serious pathology
• Unremitting pain –
inflammatory pathology
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Does the patient have any difficulty
sleeping because of the symptoms?
Does the pain wake the patient during
sleep?
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• Night time pain –
muscle tears
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Probe deeper as to the quality of pain that
cause such disturbance in sleep pattern
Determine worst and best sleeping
positions
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Incorporated in the patient care plan as
interventions should increase patient’s
comfort and ability to sleep
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24-Hour Behavior:
Morning Pain
Provides information on how condition
responds to rest
Identify the course of the symptom
throughout the day
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Musculoskeletal conditions
respond well to rest
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Stiffness, if present, resolve
quickly especially with warm
shower
Morning pain lasting more than
30 minutes is a sign of
inflammatory arthritis
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AGGRAVATING/ALLEVIATING
FACTORS
What activities/positions aggravate/relieve the symptoms?
Knowledge of these may help in the diagnosis (identifies
presence or absence of a mechanical problem), plan for
physical examination, and the formulation of management
Pain aggravated by activity or relieved by rest can be suspected
to arise from a pathologic process except in the case of a disk
problem that is aggravated by sitting and relieved by walking
and standing up
Arthritic conditions cause pain on the weight-bearing joints
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Early stage: pain with prolonged walking or maintenance of weightbearing
Late stage: pain prior to start of movement/walk that decreases
while walking then returns after prolonged walking
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The ease with which a condition is exacerbated by
movement
Three key questions to ask in order to determine the
irritability of a condition:
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IRRITABILITY
What activity (and how much) aggravates symptoms?
How severe is the pain?
After cessation of the activity, how long till the pain returns to resting
level?
What irritability of a condition provide the therapist?
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How many and what active movements to examine
How far through the range of movement should the examination be
performed
Which examination procedures to perform
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Previous episodes of the same condition will provide
the therapist guidelines for:
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PAST HISTORY
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Prognosis: duration and features may be similar to the
previous condition
Treatment: identify which techniques are effective or not;
additional intervention may be needed to prevent recurrence
of the condition (if contributing factors have been wellestablished)
Diagnosis
Patient may have a different condition in the past that
may have predisposed him/her to the current
condition
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PAST MEDICAL HISTORY
State of general health
Recent unexplained weight loss
Presence of osteoporosis
Cord signs
Dizziness
Provide precautions or
contraindications to
Headache
various treatment
Other joints
strategies
Operations
Renal dialysis
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FAMILY HISTORY
Note disease process that have a familial
incidence
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Tumors
Heart disease
Arthritis
Allergies
Diabetes
Family history predisposes a patient to increased
risk for acquiring the same condition
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PERSONAL SOCIAL HISTORY
• Social History
• Employment status and requirements
• Domestic role
• No. of dependents
• Recreational activities
• Living conditions
• Lifestyle
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MEDICATIONS
Identify what medications the patient is taking,
indication, dosage
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Analgesics
Steroid intake
Maintenance medications
Side effects of the medications should be
considered as these may interfere with the
treatment
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ANCILLARY PROCEDURES
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Either rule out or confirm the presence of
a condition that result to the patient’s
symptoms
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Laboratory and diagnostic test performed
Review of available records
Review of other clinical findings
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CHIEF COMPLAINT and
PATIENT’S GOALS
Usually stated as the problem that bothers them the
most
Can be written verbatim: patient’s own words
Patient’s goal/s
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Is it realistic? Is it achievable?
Allows the patient to have an active role in the planning of the
treatment program
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OBJECTIVE ASSESSMENT
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Facilitate or confirm the interpretation of
subjective findings
Quantification of objective data allows
documentation the patient’s baseline level of
function or status  accurate assessment of
patient’s progress following a series of treatment
sessions
Test and measures vary depending on the
following:
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Area to be examined
Information obtained from the subjective assessment
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OBJECTIVE ASSESSMENT
Ocular Inspection
Palpation
Range of Motion
Joint play
Muscle
Performance/Motor
control
Posture
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Special Tests
Anthropometric
measurements
Gait, locomotion, and
balance
Functional assessment
Environmental
assessment
OCULAR INSPECTION
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• Manner of arrival
• Swelling
• Trophic skin
changes
• Atrophy
• Gross
deformities
• Ambulatory: independent or with
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device or dependent on caregiver for
mobility
Facial expression: apprehensive,
restless, depressed, in discomfort
• Body type
• Ectomorph, endomorph, mesomorph
• Level of consciousness
• Attachments: cast,
fixation devices,
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PALPATION
The therapist should take note of the following:
Grading of tenderness
• Tenderness
Grade I: pt complains of pain
• Swelling
Grade II: pt complains of pain and winces
• Variations in temperature Grade III: pt winces and withdraws the part
Grade IV: pt does not allow palpation
• Muscle spasm
Swelling
• Differences in tissue texture
Bony/hard: osteophyte formation
• Abnormal sensation
Abnormal Sensation
Dysesthesia: diminished sensation
Hyperesthesia: increased sensation
Anesthesia: absence of sensation
Crepitus: grating, creaking upon movement of
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a limb usually
in the joint or tendinous unit
Boggy, spongy: synovial
Soft, pliable, fluctuating: fluid
Hard, thick, gel-like, warm: blood
Thick, non-fluctuating, warm: pus
Tough, dry, leathery:callus
Thick, slow moving, indentation
after pressure: pitting edema
RANGE OF MOTION ASSESSMENT
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Ask the patient to perform the painful
movement as a baseline for your assessment
Observe / palpate the movement of the other
joints
Watch out for trick movements
Check the end-feel
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Range of Motion:
Active ROM
The therapist should note the following:
• When and where during the movement onset of pain
occurs
• Whether the movement increases the quality of pain
• Patient reaction
• Amount of restriction and its nature
• Pattern of movement
• Quality of movement
• Movement of associated joints
• Willingness of the patient to move the segment
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Range of Motion:
Passive ROM
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The therapist should note the following:
• When and where during movement the pain begins
• Whether the movement increases the intensity and
quality of pain
• Pattern of limitation of movement
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Capsular or non-capsular
End feel of movement
Movement of associated joints
Range of motion available
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JOINT PLAY ASSESSMENT
Joint play refers to the small amount of ROM that can be
obtained passively: ~4mm
The therapist should take into consideration the following:
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Patient should be relaxed and fully supported
Use firm and comfortable grasp
Examine one joint and movement at a time
Test the unaffected side first
As one surface is moved, the other is stabilized
Movements should not be forced
Movements should not cause discomfort
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MUSCLE PERFORMANCE
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The therapist should assess various components of
muscle performance (if appropriate):
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Strength
Muscular endurance
Power
Agility
Use of manual muscle test (MMT), functional muscle
test, fitness testing tools to determine baseline
function of individual muscles or groups of muscles
When testing postural muscles, instead of using
standard MMT, use motor control assessment
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POSTURE
• Provides information as to the probable cause of
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the deformity
The therapist should note the following:
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Difference in alignment of the body segments: asymmetry
Presence of upper/lower crossed syndromes
• Guidelines:
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Patient appropriately undressed
No shoes, socks, stockings
Note use of walking aids, braces, etc.
Examine in the habitual, relaxed
posture
Assess in standing, sitting, and lying
positions
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Weak
lengthened
phasic
muscles
Tight
hypertonic
postural
muscle
JOINT
Weak
lengthened
phasic
muscles
Tight
hypertonic
postural
muscle
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SPECIAL TESTS
Allows the therapist to:
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Confirm a tentative diagnosis
Make a differential diagnosis
Differentiate between structures
Understand unusual signs
Unravel difficult signs and symptoms
Some tests have poor reliability and validity therefore the
therapist should use these with caution
Findings depend on the skill and ability of the examiner to
perform and identify (+) and (-) signs
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ANTHROPOMETRIC MEASUREMENTS
Helps in formulation of a diagnosis/impression regarding the
patient’s condition (leg length discrepancy), in prognosis
(swelling), and in identifying the patient’s body type (skinfold
measurement)
Performed in the presence of:
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Swelling
Asymmetry in limb girth
Postural and gait deviations
Amputation
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GAIT, LOCOMOTION ASSESSMENT
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Majority of gait assessment is observation
The therapist should take note of the following:
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Presence of gait deviations: abnormal gait patterns
Difference between the right and left lower extremity during specific
cycles/phases of gait
Compensatory mechanisms
Speed and cadence of walking
Guidelines:
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The patient should be assessed both in normal footwear and in bare
feet
Take time to observe the patient during gait assessment
Assess in the anterior, posterior and lateral views
Note use of gait aids, etc.
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Uses of functional assessment:
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FUNCTIONAL ASSESSMENT
Helps the therapist establish what is important to the patient and
the patient’s expectations
Represents a measurement of a whole-body task performance
ability
Determines the effect of injury to the patient’s daily
functions/activities
May involve task analysis, use of various functional
assessment tools, fitness profiles
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ENVIRONMENTAL ASSESSMENT
Home or workplace assessment provides the therapist
information regarding the influence of the patient’s
environment to the present condition
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Are there any barriers to normal movement that predispose the
patient to certain conditions?
Are modifications necessary to allow proper performance of
activities?
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NEUROLOGIC ASSESSMENT
Performed in certain conditions that involve neurologic
structures
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Nerve lesions: peripheral nerve injuries
Provides baseline information regarding the integrity of
the patient’s neural structures
The therapist assesses the following:
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Sensation
Deep tendon reflexes
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PRINCIPLES OF EXAM.
Tell the patient what you are about to do. Acquire consent.
Test the uninvolved side first
Do active movements first, then passive movements,
followed by resisted movements
Painful movements are performed last
In testing end feel, apply overpressure carefully
Repeat movements or sustain postures/positions if history
indicates
Resisted isometric movements should be performed in a
resting position
Warn the patient of possible exacerbation of symptoms
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PRINCIPLES OF EXAM.
With passive movements and ligamentous testing, both the
degree and quality of movement are important
With ligamentous testing, repeat with increasing stress
With myotome testing, contractions must be held for five (5)
seconds
Maintain the dignity of the patient: perform assessment
procedures in a closed cubicle if available, drape
appropriately
Refer to other professionals it necessary
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QUESTIONS???
THANK YOU
FOR
LISTENING!
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REFERENCES
Hertling, D. and Kessler, R. (1990). Management of common
musculoskeletal disorders: Physical therapy principles and
methods (2nd ed.). San Francisco: J. B. Lippincott Company.
Loudon, J., Bell, S., and Johnstin, J. (1998). The clinical
orthopedic assessment guide. USA: Human Kinetics.
Magee, D. (2002). Orthopedic physical assessment (4th ed.).
Singapore: Elsevier Sciences.
Refshauge, K. and Gass, E. (1995). Musculoskeletal
physiotherapy: Clinical science and practice. London:
Butterworth-Heinemann Ltd.
Starkey, C. and Ryan, J. (1996). Evaluation of orthopedic and
athletic injuries. USA: F. A. Davis Company.
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